D 161 Healthcare Improvement Project Template (HIP) – Project Evaluation And Closure (Capstone)

• MBD 161 Healthcare Improvement Project Template (HIP)

Student name

Western Governors University

Leavitt School of Health

Prof. name

Submission date

Nursing Leadership and Management Capstone

The Global Care Wellness Centre Healthcare Improvement Project (HIP) provides evidence-based approaches for reducing inpatient falls. The main activities of the project are the application of innovative fall prevention technologies, modification of the physical environment, and implementation of staff training courses. Targeting high-risk patients and using methodical fall risk assessments would help the project greatly lower fall events, enhancing patient safety and lowering healthcare costs (Morat et al., 2023).

The general goal of the assessment is to examine the successes and difficulties encountered during the project and to assess the performance of HIP in general. Utilizing staff training, environmental changes, and fall risk assessments, Global Care Wellness Center’s fall prevention project sought to lower patient falls. This assessment looks at the effectiveness, costs, and result of these interventions and explores what went well and what barriers there were to achieving the desired outcomes.

To assess the success of the project, this assessment will underline important Key Performance Indicators (KPIs), such as the drop-in fall incidence rates and staff training completion rates. It will also examine the financial aspects associated with the project, such as cost comparisons and the viability of putting in place solutions (Morat et al., 2023). The evaluation looks at the lessons learnt and areas for development as well as providing insight into closing the project. The goal for this evaluation is to give practical recommendations for future quality improvement efforts in medical facilities and the study is to be evaluated on effectiveness on closing policies, financial results and performances of the process.

Evaluation of the Project

Comparison of KPIs with the SMART Goal

The project aimed to lower the rate of falls by 30% by the end of December 31, 2024, by using staff training, changing the environment, and fall risk assessments.

1. Process KPI #1: Staff Training Completion Rate

This KPI measures the proportion of nurses who have undertaken fall prevention training. While this KPI is important for the project’s success, it is not a process KPI, but rather an output measure (Făgărășan et al., 2023). The target was to achieve 90% staff training completion, and by the end of the project, 98% of the staff had completed training. 

2. Process KPI #2: Frequency of Fall Risk Assessments

The second KPI monitors the rate at which fall risk assessments are carried out on high-risk patients. This KPI is measurable, but it did not specify the percentage in the assessment. It should have indicated a specific % or frequency for the SMART goal to be aligned with. On admission, 100% of high-risk patients had a fall risk assessment, but throughout the project, there was not a set percentage of patients that had fall risk assessments, which did not make this KPI a SMART goal.

Comparison of KPI Results to SMART Goal

• SMART Goal Achievement: The SMART goal to be achieved was a reduction in falls by 30%. The falls were reduced by 23%, and, while this is a significant reduction, it is still not the 30% level (Făgărășan et al., 2023).
• KPI Impact: In terms of KPI Impact, the KPI outcomes in the areas of staff training and fall risk assessments were positive (high completion rates), but did not ensure the full impact of the KPI for the falls reduction target of 30% (Saad Mohammad Alsaad et al., 2024). The need for fall arrest equipment and personnel resistance to change were the reasons for the shortfall.

Project Efficiency and Effectiveness

A review of how time and money were used during the implementation of the fall prevention project can provide one with an evaluation of how effective the project was. The project was originally intended to be six months long, but overall, with minor trainings staff that were delayed due to scheduling, it came together. Resources assigned to the project and most used included training materials, staff time and technology investments such as fall prevention equipment. The integration of Learning Management Systems (LMS) to record training completion and Electronic Medical Records (EMR) to monitor in real time enabled state resource management (Libadia et al., 2025).

The project was able to proceed within budget and on schedule, with some resource-related challenges, such as the acquisition of a number of fall prevention technologies. A big part of the explanation for the 23% decline is related to effective staffing, environmental, and technology (edtech) changes. However, delays in the process of changing personnel and equipment slowed down the schedule. These components suggest that in the future, buffer times should be built into intervention programs and that resources should be more efficiently allocated to prevent delays and maintain the effectiveness of the intervention.

 Effectively, the interventions carried out during the project helped to lower patient fall rates. The project was higher than the 20% objective and actually resulted in a fall event reduction of 23%. This result shows that the interventions that comprised staff training, environmental changes (e.g., non-slip flooring, better lighting), and fall risk assessments (e.g., Morse Fall Scale) were quite successful (Luebbert et al., 2022). 98% completion rate of fall prevention training for employees indicated improved competency and buy-in to the fall protection procedures. Together, these created safer patients and enhanced the patient-centered care environment. There was a positive effect of the fall prevention plan as the project was efficient in terms of resources and was successful in achieving the project goal of reducing patient falls.

Timeline Comparison

The Global Care Wellness Centre’s fall prevention project set a staff training deadline of six months, as well as environmental changes, and fall risk assessments. On July 1st, 2024, the project began and is set to end by December 31st of that year; the unexpected delays in acquiring needed fall protection equipment, such as non-slip flooring and bedside alarms, extended the timeframe by three weeks, thus pushing the completion date to mid-January, 2025. Difficulties in coordination with suppliers of specialized fall prevention technology, where it was needed and required further authorization and procurement time, were the main reasons for the delays (Kuoppamäki, 2021). In addition, staff resistance to change contributed to some training course delays, as some staff initially resisted implementing the fall-prevention strategies.

This reluctance was overcome, and accelerated training was achieved by mentorship programs and leadership-driven motivating tactics. Procurement problems and opposition during training caused the project to be extended by three weeks. However, all significant milestones were achieved in the adjusted timeline, ensuring all key interventions were made on time and had impact assessments (Widdows et al., 2021). The delay did not have an impact on the overall project timeline, but it did mean that some of the key project activities, including the risk assessments and staff development, were completed prior to the revised schedule. An extension of three weeks was requested to allow for the resolution of minor implementation issues and to allow a more thorough evaluation of the project’s effectiveness, ensuring that all planned activities were implemented successfully.

Budget Comparison

The Healthcare Improvement Project (HIP) had an initial ProForma budget of $14,404.49 (including staff and non-staff costs) at Global Care Wellness Center. A major part of the budget was staff expenditures; the rest of the budget was made up of various expenses, including training, equipment, and consulting fees. The ultimate costs, though, during the real execution came to $16,404.49, which left a $2,000 difference. Unexpected costs, including longer training times, extra equipment, and unforeseen operational changes, were responsible for this difference.

The project did experience an increase in budget, particularly due to the length of delays in procurement of equipment and staff training, but was still within reasonable boundaries [See Appendix E]. Thus, while the project wasn’t necessarily on a strict budget, it was still within an acceptable range of $2,000. Relatively near the ProForma projected $14,404.49, the final expenses of $16,404.49 suggest that the project was well run and within budget despite some unanticipated expenses. The small increase reflects the compromise needed to overcome practical issues while still achieving a project’s goals and maintaining financial accountability.

Final Budget Template

Proforma Item	Proforma Cost (From Original Proforma)	Actual Cost	Variance	Cause of Variance
Personnel Costs	$8,944.49	$9,944.49	+$1,000	Increased due to additional training sessions and extended training duration
Project Manager	$3,365.00	$3,365.00	$0	No change in the actual cost
Chief Nursing Officer (CNO)	$576.90	$576.90	$0	No change in the actual cost
Director of Quality Improvement (DQI)	$685.05	$685.05	$0	No change in the actual cost
Chief Medical Officer (CMO)	$423.04	$423.04	$0	No change in the actual cost
Quality Improvement Specialist	$2,043.50	$2,043.50	$0	No change in the actual cost
Data Analyst	$1,081.80	$1,081.80	$0	No change in the actual cost
Implementation Coordinator	$769.20	$769.20	$0	No change in the actual cost
Non-Personnel Costs	$5,460.00	$5,460.00	$0	No change in the actual cost
Training and Development Costs	$1,500.00	$1,500.00	$0	No change in the actual cost
Equipment and Supplies	$2,000.00	$2,500.00	+$500	Increased due to the unexpected procurement of advanced fall-prevention equipment
Consultation Fees	$1,000.00	$1,000.00	$0	No change in the actual cost
Miscellaneous Expenses	$960.00	$1,460.00	+$500	No change in the actual cost
Total Project Cost	$14,404.49	$16,404.49	+$2,000	Increased due to extended training time and extra equipment procurement

Project Closure

Project closure includes a final report, a meeting with stakeholders, and transfer of responsibility for training. To ensure a degree of synergy with all concerned, a formal closure document with completion checklists/sign-offs was used. This material helps to make sure the project will be sustainable, and the project interventions will be effective. In completing the fall prevention project at Global Care Wellness Centre, the project adopted a systematic approach in ensuring the resources were also used efficiently and that all the activities were completed (Morat et al., 2023).

This was the first time that a final status report was completed, which summarised the results of the project, such as the fall reduction rate, the number of staff completing the training, and compliance with the fall risk assessments, and so was able to assess the overall project. An end review meeting was then conducted with the project team that included key stakeholders, including hospital managers, nursing leadership, and the quality improvement team.

This conference would allow one to reflect on the achievements of the project, the issues and concerns, and those that have not been addressed. The team also discussed their budget and pulled the differences between the budget and actual for all team members. The workers employed a delivery procedure with continual fall prevention techniques in order to ensure the sustainability of the project. This involved shifting the responsibility for staff education to the continuous education division of the hospital and making sure that all new staff would be continuously educated about falls prevention.

The hospital’s routine safety measures also included fall alerting devices, such as sounds that alert the staff if a patient has started to leave their bed, and the installation of non-slip floor surfaces. The documentation of all lessons learnt and recommendations offered for future projects was then used by the leadership of the hospital. The project came to fruition successfully and was well managed in terms of resources and in completing all the project tasks.

Recommendations and Lessons Learned

Recommendations for Future Projects

Global Care Wellness Centre’s fall prevention program calls for several healthcare improvement projects.

• Plan for Equipment Procurement

Give sufficient time to planning equipment purchase and to allow for a time lag in assuring needed technology. However, the time taken to obtain new fall prevention equipment, like motion sensors and automated alarm systems, put an extra strain on time and thus added unintended costs to this Work (Visvanathan et al., 2021). In future projects, more realistic time estimation for equipment should be set in order to avoid project delay, and more time buffers should be allowed.

• Engage Staff Early

There is also a high level of encouragement that staff will be involved from an early stage in the process. The resistance of staff members towards change at the beginning of the project was one of the greatest challenges that faced the success of this project (Jewell et al., 2020). To that end, it is important to enable the leadership to engage people in the decision-making process and incentivize participation, and change management processes should be used. This would work to diminish opposition and build support for new projects.

Lessons Learned

• Continuous Stakeholder Engagement

Among the most crucial lessons learned was the importance of continued stakeholder engagement (Făgărășan et al., 2023). Frequent meetings with the nursing management, hospital administration, and the quality team helped to take quick action to rectify the issues and optimize resources.

• Ongoing Training and Refresher Courses

Future actions should emphasise that continuous learning and refresher courses are needed to ensure continued improvements (Libadia et al., 2025).

• Utilizing Monitoring Systems

Since monitoring platforms like EMR and LMS have become an important factor in data collection and analysis, tracking of development in future healthcare improvement should be implemented for correct data collection and analysis.

Next Steps

The next actions concentrate on continuous monitoring and extending the fall prevention campaign over the healthcare institution, guaranteeing its durability and continuous success.

Monitor Progress

Track fall rates and evaluate the continuous success of the intervention, depending on regular audits and data collection utilizing Electronic Medical Records (EMR). The information will guarantee that all pertinent staff members comply with fall-prevention training and aid in pinpointing any areas needing work (Ware et al., 2025). Early identification of problems can also be made with evaluation each week, which can be used to make changes to the program as needed.

Expand the Program

The fall prevention program should be expanded to other departments of the hospital if a broader impact is desired. This development will enable uniform patient safety protocols all over the institution (Ware et al., 2025). Safety procedures will be integrated into the programme, with plans in place to provide feedback to different groups of patients on the initiatives to ensure the programme is effective and responsive to the needs of the different groups.

Conclusion

The Healthcare Improvement Project (HIP) was one of the evidence-based strategies that the Global Care Wellness Centre (GCWC) used to decrease the number of patient falls on the inpatient unit. These were primarily innovative fall prevention equipment, staff in-service training, and modification of the environment. The aim of the program was to reduce patient falls by 20% through staff competency, improving safety measures, and conducting methodical fall risk analyses. They were able to accomplish more than they had envisioned for this project.

The result of the initiative showed the success of the applied treatments, as there was a decrease of 23% in the autumn events. A fall risk assessment was also performed on a regular basis, and the fall prevention training was taken by 98% of employees. Immediately, these outcomes helped to lower care costs, improve patient safety, and create a more secure hospital environment. Global Care Wellness Centre’s HIP was successful because of a few factors. Staff participation was a significant enabler – most of the nurses attended the fall prevention course. Effective management, especially the participation of quality improvement teams and nurse managers who guided and supplied resources throughout the implementation phase, also helped the project to be successful.

Also, the technology of the project, such as motion sensors and Electronic Medical Records (EMR) that tracked falls, has played an important role in improving the effectiveness of the project. The project progressed, however, with many obstacles. One of the main obstacles to the project in the initial stages was the lack of staff acceptance of change. Initially, there was resistance from a few members of the staff to adhere to new fall prevention guidelines for the fall season. Peer mentoring and participation of leaders helped to counteract this.

The other challenge that caused some delays was budget constraints, which precluded the procurement of a number of fall protection tools such as advanced alarm systems. These delays placed greater time on the project and caused unexpected expenses. This project required a lot of leadership and project management skills in order to be successful. Thanks to the good leadership, these multidisciplinary teams were working together and directed. Promoting the objectives of the project and guaranteeing adherence to fall-prevention strategies depend much on nurse leaders.

To break through the initial resistance to change, they needed to have the ability to communicate the advantages of the change and to involve staff at every level. As far as project management, although there were setbacks, good organizing skills and clear planning were able to keep me on track and on schedule with this project. The project continued to be both data-driven and outcomes-based and incorporated monitoring mechanisms to track fall events with the use of the EMS and staff training with the LMS. These project management and leadership skills were essential in tackling challenges such as resistance to change and challenges with equipment procurement. A leadership team was able to successfully implement the project, reduce fall incidence, and improve patient safety by constantly communicating with staff, making changes based on feedback, and becoming involved in the project.

References

Făgărășan, C., Cristea, C., Cristea, M., Popa, O., & Pîslă, A. (2023). Sustainability, 15(17), 13139–13139. https://doi.org/10.3390/su151713139

Jewell, D. O., Jewell, S. F., & Kaufman, B. E. (2020). Human Resource Management Review, 32(1), 100749. https://doi.org/10.1016/j.hrmr.2020.100749

Kuoppamäki, S. (2021). The application and deployment of welfare technology in Swedish municipal care: A qualitative study of procurement practices among municipal actors. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06944-w

Libadia, M., Botangen, K. A., Lucero, P. J., & Tecson, J. (2025). Development of a web-based records management system: An erms initiative for the office of senior citizen affairs in the Philippines. Records Management Journal, 4(4). https://doi.org/10.1108/rmj-06-2023-0031

Luebbert, S., Christensen, W., Finkel, C., & Worsowicz, G. (2022). Falls in senior adults: Demographics, cost, risk stratification, and evaluation. Missouri Medicine, 119(2), 158. https://pmc.ncbi.nlm.nih.gov/articles/PMC9339401/

Morat, T., Snyders, M., Kroeber, P., De Luca, A., Squeri, V., Hochheim, M., Ramm, P., Breitkopf, A., Hollmann, M., & Zijlstra, W. (2023). BMC Geriatrics, 23(1). https://doi.org/10.1186/s12877-023-03810-8

Pidgeon, A., & Dawood, N. (2021). Bridging the gap between theory and practice for adopting meaningful collaborative BIM processes in infrastructure projects, utilising Multi-Criteria Decision Making (MCDM). Journal of Information Technology in Construction, 26(4), 783–811. https://doi.org/10.36680/j.itcon.2021.043

Pradhan, B., Bhattacharyya, S., & Pal, K. (2021). IoT-based applications in healthcare devices. Journal of Healthcare Engineering, 2021(1), 1–18. https://doi.org/10.1155/2021/6632599

Saad Mohammad Alsaad, Mshari Alabdulwahed, Nabeel Mohammed Rabea, Shabana Tharkar, & Alodhayani, A. A. (2024). Healthcare, 12(4), 472–472. https://doi.org/10.3390/healthcare12040472

Ware, A. M., Murray, D., & Gill, N. W. (2025). CIN Computers Informatics Nursing, 4(8). https://doi.org/10.1097/cin.0000000000001256

Widdows, K., Roberts, S. A., Camacho, E. M., & Heazell, A. E. P. (2021). PLOS ONE, 16(4), e0250150. https://doi.org/10.1371/journal.pone.0250150